Program of Excellence<

Program of Excellence Registration

Player Profile Form

Program:
Hockey MB Region:
First Name:
Last Name:
Address:
City/Town:
Province: MB    Postal Code:   
Home Phone:
Birthday: / /
Sex:
Mother's Name:
Father's Name:
Alternate Phone #s:  
   
E-MAIL IS OUR PRIMARY METHOD OF COMMUNICATION. PLEASE LIST ACTIVE E-MAIL ADDRESSES:
Player's E-mail:
Mother's E-mail:
Father's E-mail:
PERSON TO CONTACT IN CASE OF EMERGENCY, IF PARENTS UNAVAILABLE:
Name/Relationship:
Emergency Phone:
Emergency Cell:
Doctor's Name:
Doctor's Phone:
Dentist Name:
Dentist's Phone:
Provincial Health #:
Shot:
Height:     Weight:   
Position:
Current Team Name:
Category:
Division:
Coach:
Coach's Phone:
Coach's Cell:
PLEASE SELECT THE APPROPRIATE RESPONSE BELOW:
Yes  No Previous history of concussions
Yes  No Epileptic
Yes  No Fainting episodes during exercise
Yes  No Wears Glasses
Yes  No Are lenses shatterproof?
Yes  No Wears Contact Lenses
Yes  No Wears dental appliance
Yes  No Hearing problem
Yes  No Trouble breathing during exercise
Yes  No Asthma
Yes  No Heart Condition
Yes  No Diabetic
Yes  No Has had an illness lasting more than a week in last year
Yes  No Has had injuries requiring medical attention in last year
Yes  No Wears Medical Alert ID
Yes  No Allergies
Yes  No Surgery in the last year
Yes  No Medication
Yes  No Has been hospitalized in last year
Yes  No Presently injured
PLEASE GIVE DETAILS IF YOU ANSWERED YES TO ANY OF THE ABOVE ITEMS:
Last Tetanus Shot: / / (mm/dd/yyyy)
Last Complete Exam: / / (mm/dd/yyyy)
APPAREL SIZING INFORMATION:
T-Shirt Size:
Shorts Size:
Jacket Size:
ANY MEDICAL CONDITION OR INJURY SHOULD BE CHECKED BY YOUR PHYSICIAN BEFORE PARTICIPATING IN A HOCKEY PROGRAM.
** all fields are required
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